Sir, with reference to the article on the management of patients with reduced oral aperture and mandibular hypomobility (BDJ 2008; 204: 125–131) and a letter entitled Submucous fibrosis (BDJ 2008; 204: 421) we would like to share with your readers some observations from a country where submucous fibrosis is very common.

Areca nut or betel nut is the seed of the Areca palm called Areca catechu. The fundamental cause of this syndrome is varying degrees of fibrosis in the sub-mucosal layers and in the muscles of mastication leading to a varying degree of trismus. Most authors attribute it to areca nut consumption and partly to smokeless tobacco.1 Pan, gutka, pan masala, pan mawa etc are the popular names of tobacco and areca nut combinations in India.2 Gutka is the predominant form of areca nut consumption in most parts of India and advertised as a mouth freshener.2,3,4

The various components of this syndrome are:

Chewer's face – typically affecting young or middle-aged persons but also schoolchildren.5 It may develop within five years of the habit starting and can include features such as: sunken and stiff cheeks due to loss of facial and buccal fat through chronic malnutrition and fibrosis of the cheek muscles; pseudo-proptosis due to loss of facial, especially peri-ocular fat; pseudo malar prominence due to loss of subcutaneous fat in the peri-orbital area and sunken cheeks.

Chewer's mouth – which shows: pale white oral mucosa, a varying degree of trismus with reduced oral aperture, poor oral hygiene, bald tongue due to loss of papilla, chronic non-healing ulcers in the oral mucosa, extreme sensitivity to heat, cold and spices, retracted soft palate with forward pointing uvula, unhealthy gingivae – chronic gingivitis or gingival recession, unhealthy teeth – teeth are sensitive, abnormally shaped, mal-aligned, premature loss and higher caries incidence, last molar buried in the adjoining buccal mucosa, loss of gingivo-buccal sulcus, loss of tonsillar bulge, reduced salivary outflow due to fibrosis around the Stenson's duct opening.

Chewer's speech – due to progressive fibrosis, the tongue and lip become stiff, resulting in alteration of speech.

Chewer's swallowing – avoidance of eating in public due to reduced mouth opening and consequent inability to eat routine food, altered swallowing due to loss of suppleness of tongue, reduced salivary outflow, dysphagia which although rare causes the oesophagus to show signs of progressive fibrosis and narrowing.

Chewer's hearing impairment – due to fibrosis around the eustachian tube opening.

The consumption of gutka or similar products has not only been reported from Asia but also from the Western world. These individuals with submucous fibrosis have a higher incidence of developing oral cancers.4